Deficiency Records for Mary Health of The Sick Convalescent and Nursing Hos
Updated as of March 01, 2024
A list of the most recent deficiencies for Mary Health of The Sick Convalescent and Nursing Hos. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-02-10 | 2023-03-16 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-02-10 | 2023-03-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-10 | 2023-03-16 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-02-10 | 2023-03-16 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-02-10 | 2023-03-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-10 | 2023-03-16 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-02-10 | 2023-03-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-10 | 2023-03-16 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-02-27 | 2023-03-14 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-02-27 | 2023-03-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-27 | 2023-03-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-27 | 2023-03-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-27 | 2023-03-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-27 | 2023-03-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-19 | 2019-12-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-19 | 2019-12-05 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-11-19 | 2019-12-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-19 | 2019-12-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-10 | 2019-11-08 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-10-10 | 2019-11-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-10 | 2019-10-10 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-01-25 | 2019-02-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-01-25 | 2019-02-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-01-25 | 2019-02-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-25 | 2019-02-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-01-25 | 2019-02-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-10-04 | 2018-10-31 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-10-04 | 2018-10-31 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-10-04 | 2018-10-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-04 | 2018-10-31 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-10-04 | 2018-10-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-04 | 2018-10-31 | N |
